"Pregnancy Complicating Diabetes" (1949), by Priscilla White

By Blaise Castagnetti
Published: 2017-10-24
Keywords:

"Pregnancy Complicating Diabetes" (1949), by Priscilla White

In 1949, Priscilla White published "Pregnancy Complicating Diabetes,"
which described the results and implications of a fifteen-year study
about pregnant diabetic women. Published in the American Journal of
Medicine, the article details possible causes of and ways to prevent
the high fetal mortality rate associated with pregnant diabetic women.
Diabetes is a disease in which the body's ability to produce or respond
to the hormone insulin is impaired, and it can be particularly dangerous
during pregnancies. In her article, White reported that prematurely
delivering infants for diabetic pregnant women reduces infant and
maternal mortality rates. "Pregnancy Complicating Diabetes" helped make
premature delivery of infants the standard of care for diabetic pregnant
women, and it has contributed to the increased survival rate of infants
born from diabetic mothers from less than fifty percent in the 1940s to
over ninety percent in 2017.

White cared for over 2,000
diabetic patients throughout her career and studied how diabetes affects
women who become pregnant and their infants. She conducted the study
discussed in "Pregnancy Complicating Diabetes" while working at the
George F. Baker Clinic in Boston, Massachusetts, where she cared for
diabetic women and children. White spent most of her career studying the
effects of diabetes in young children and in pregnant women, as well as
the effects that diabetes has on infants born from diabetic mothers. The
survival rate of infants born from diabetic mothers was below fifty percent when
White started working at the George F. Baker Clinic.

Her
article is a summary of a study done at the George F. Baker Clinic of
the New England Deaconess Hospital in Boston, Massachusetts which was
conducted to determine possible causes and the means to prevent the high
fetal wastage in diabetic pregnancies. It was a fifteen-year study that
lasted from 1934 to 1949. The study included 439 viable diabetic
pregnancy cases.

In her article, White discusses the study
itself and analyzes data into four different tables. The first table
displays the medical conditions that were associated with fetal
fatalities. The second table depicts the amount of time the patients in
the study had been living with diabetes, and how it was associated with
vascular complications. The third table in the article describes the
amount of cases in which pregnant women had abnormal, corrected, or
normal amounts of sex hormones. The final table in the article divides
the patients into classes A through F, which corresponds to fetal and
maternal risks. Class A had the lowest risk, and Class F had the highest
risk of complications to both the pregnant women their fetuses. Based on
which class the patients were placed in, the researchers gave specific
dosages of sex hormones such as stilbestrol and proluton.

In
the beginning of her article, White describes the patients who
participated in the study. Next, White moves on to her findings and
discusses a table that contains data about infant mortalities, the
conditions associated with fetal deaths, and the frequency of those
conditions. As White details, "Table 1: Relative Frequency of Conditions
Associated with Seventy-Eight Fetal Deaths" shows that fetal fatality
occurred in seventy-eight of the 439 cases, or eighteen percent of those
times. Of those seventy-eight fetal deaths, thirty-four were stillbirths
and forty-four occurred in the neonatal period, which is the period that
extends to a month after birth. Conversely, maternal fatality only
occurred in one woman out of 439. According to White, the only maternal
death occurred fifty days after delivery, and was caused by infectious
hepatitis. White concludes that the main concern should be the fetus,
not the mother.

Next, White discusses whether the length of
time a person had lived with diabetes caused vascular complications, or
complications that affect the vessels that carry blood throughout the
body. The section includes a second table, "Table II: Duration of
Diabetes and Vascular Complications." White details how a survey was
conducted as part of the study, given to the pregnant women that were
diagnosed with diabetes before age fifteen and then lived at least
twenty years with the disease. According to White, the survey showed
that ninety-three percent of those patients had symptoms of vascular
disease. From the survey data, White concludes that long duration of
diabetes and early onset of the disease are associated with more than
half of the fetal fatalities. White also notes that sixty-eight percent
of the thirty-four stillbirths occurred late in pregnancy. From that,
White argues that further research should be done on delivering the
infant earlier in pregnancy, rather than letting it go its full course
in order to avoid the death of an infant. Because a large percentage of
the stillbirths occurred late in pregnancy, White considered that
prematurely delivering the fetus was a possible treatment option for
diabetic pregnant mothers.

A year prior to the publishing of the
paper was the invention of the clinical grading scale of diabetic
patients. This grading scale went from Class A through E, corresponding
to the least fetal risk, or Class A, to the most fetal risk, or Class E.
Class A is the one corresponding to the highest chance for fetal
survival, and patients classified in Class A did not need dietary
regulation or any insulin injections. Class F included all patients with
nephritis, which is swelling or inflammation of the kidneys. Of the 439
cases, five percent were Class A, twenty-nine percent were Class B,
forty-four percent were Class C, fourteen percent were Class D, seven
percent were Class E, and one percent were Class F. The most common
classification was Class B, which indicates a fairly moderate risk.

As her article continues, White discusses a third table, which
depicts three classes of patients in regard to their sex hormone
balance. The table is titled "Table III: Summary of 433 Cases Divided
According to Sex Hormonal Balance." In the study, patients were
classified based on their sex hormone balance as abnormal, corrected,
and normal. According to White, nine of the pregnant women were
classified as abnormal, 297 were classified as corrected, and the
remaining forty-seven women as normal. White highlights that the
survival rate for women in all three classifications was above fifty
percent. The corresponding fetal survival rates for abnormal, corrected,
and normal were fifty-eight percent, eighty-nine percent, and
ninety-five percent. That proved that those with corrected sex hormones
had a very high survival rate. Very few patients were classified as
having an abnormal sex imbalance.

Next, White discusses the best
ways to prevent fetal deaths in pregnant diabetic women. First, White
says that proper treatment of the disease is the best way to prevent
fetal death, which includes proper diet and exercise. Second, White
argues that the use of hormone therapy was the most successful way to
prevent fetal death, according to fetal survival rates obtained as part
of the study. She then argues for the correction of two common
conditions associated with pregnant diabetics, swelling, and hydramnios,
or extra fluid that surrounds the fetus. Finally, White lays out two
treatments directly relevant to the fetus, which are premature delivery
and special care of the infant after birth.

After that, White
discusses the amount of hormone therapy needed in each patient according
to their clinical grade and number of weeks along in their pregnancy.
The last table, titled "Table IV: Sex Hormonal Therapy in mg of
Stilbestrol and Proluton According to Weekly Pregnancy and Clinical
Classification." Administration of hormone therapy varied from oral,
injections, and implantations of pellets. The dosage and frequency of
hormone treatment depended on the clinical grade. Class A received no
hormonal therapy, Class B and C received five to fifty mg of stilbestrol
and proluton daily, Class D from ten to seventy-five mg, and Class E and
F from 25 to 125 mg. However, that type of therapy was not required in
the study and could be done by choice as early as the sixth week of
pregnancy. Ironically, sex hormone therapy was the most favorable
treatment, as the survival rate rose from fifty-eight to eighty-nine
percent for those that received the treatment.

Finally, White
includes the controversial issues that she argues arose because of the
study. First, White writes that in patients who had been living with
diabetes for twenty or more years, their fetal survival rates were only
twenty percent. Critics of the study argued that it was pointless to
conduct the study, because even if the survival rate was increased, it
is unlikely that it would be by much. Furthermore, critics argued that
if the patient had been living with diabetes for a long time and also
had vascular disease complications, the survival rate was only ten
percent. Next, White discusses that critics argued that it was unknown
which organ in the body was responsible for the diabetes and
complications that arose because of that. The three suspects were the
endocrine glands, pituitary glands, and the placenta. However, White
concedes that her study did not determine if it was one, or a
combination of the three glands in the human body that caused diabetes
onset. At the end of the article, White states that although the fetal
survival rate is ninety percent, diabetic pregnant women will not have
the same experience during pregnancy as normal women.

When White
published her article in 1949, it brought attention to the issue of
pregnant diabetic women and the health outcomes of giving birth for both
the pregnant woman and the infant. As of 2017, the article has been
cited over 500 times. White took the treatments she used in the study
and used those treatments at the Joslin Clinic where she worked. Those
treatments became standard of care for pregnant women with diabetes and
changed the treatment and outcomes of diabetic pregnant women and their
infants, increasing the survival rate of both and infant and the mother
to over ninety percent.